Histopathologic and Clinical Predictors of Kidney Outcomes in ANCA-Associated Vasculitis
Histopathologic and Clinical Predictors of Kidney Outcomes in ANCA-Associated Vasculitis
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DOI：
10.1053/j.ajkd.2013.08.025
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发表时间：
2014-02-01
影响因子：
13.2
通讯作者：
Summers, Shaun A.
中科院分区：
文献类型：
--
作者：
Ford, Sharon L.;Polkinghorne, Kevan R.;Summers, Shaun A.
背景：最近提出了一个预测性组织学分类来确定抗中性粒细胞胞浆抗体相关肾小血管炎(AAV)患者肾活检的预后价值。研究设计：一项双重目的的回顾性观察队列研究，以评估新分类和预测结果的临床变量的可重复性。背景与对象：169名连续的AAV患者，145例纳入重复性研究，120例纳入结果研究。预测因素：肾活检标本根据主要的肾小球病变分类：局灶性、混合性、新月体和硬化性。对肾小管萎缩的评估也进行了。结果：主要结果是终末期肾脏疾病的时间或全因死亡率，使用COX回归分析。测量：估计肾小球滤过率，肾脏替代治疗的需求。结果：对于重复性研究，分类的总体评价者间可靠性在3个组织病理学家之间表现出差异(组内相关系数，0.48；95%可信区间，0.38-0.57；卡帕统计量=0.46)。尽管硬化组的一致性很高(kappa=0.70)，但在其他组中一致性较差(新月体、灶性和混合性分别为kappa=0.51、kappa=0.47和kappa=0.23)。在临床结果研究中，肾小球损伤硬化型的患者表现出最差的结果。局灶型(HR，0.26；95%CI，0.12~0.58；P=0.001)、新月型(HR，0.33；95%CI，0.16~0.69；P=0.003)和混合型(HR，0.39；95%CI，0.18~0.81；P=0.003)的患者发生主要结局的风险较低。肾小管萎缩与预后相关，严重损伤与较差的预后相关(HR，5.9；95%CI，2.25-15.47；P<；0.001)。肾功能水平对预后有很强的预测作用(每10毫升/分钟1.73m(2)心率增加估测肾小球滤过率，0.63；95%可信区间，0.46-0.81；P<；0.001)。限制：考虑到研究的回溯性，数据可获得性。结论：该分类的重复性仅见于肾小球损伤硬化型患者。肾小球损伤的硬化模式、慢性间质损伤的进展期和肾功能下降都预示着不良预后。(C)2014年，由国家肾脏基金会，Inc.出版，Elsevier Inc.版权所有。
Background: A predictive histologic classification recently was proposed to determine the prognostic value of kidney biopsy in patients with antineutrophil cytoplasmic antibody-associated renal vasculitis (AAV).Study Design: A dual-purpose retrospective observational cohort study to assess the reproducibility of the new classification and clinical variables that predict outcomes.Setting & Participants: 169 consecutive patients with AAV were identified; 145 were included in the reproducibility study, and 120, in the outcomes study.Predictor: Kidney biopsy specimens were classified according to the predominant glomerular lesion: focal, mixed, crescentic, and sclerotic. An assessment of tubular atrophy also was performed.Outcomes: The primary outcome was time to end-stage kidney disease or all-cause mortality, modeled using Cox regression analysis.Measurements: Estimated glomerular filtration rate, requirement for renal replacement therapy.Results: For the reproducibility study, the overall inter-rater reliability of the classification demonstrated variability among 3 histopathologists (intraclass correlation coefficient, 0.48; 95% CI, 0.38-0.57; kappa statistic = 0.46). Although agreement was high in the sclerotic group (kappa = 0.70), it was less consistent in other groups (kappa = 0.51, kappa = 0.47, and kappa = 0.23 for crescentic, focal, and mixed, respectively). For the clinical outcomes study, patients with sclerotic patterns of glomerular injury displayed the worst outcomes. Patients with focal (HR, 0.26; 95% CI, 0.12-0.58; P = 0.001), crescentic (HR, 0.33; 95% CI, 0.16-0.69; P = 0.003), and mixed (HR, 0.39; 95% CI, 0.18-0.81; P = 0.01) patterns of injury had lower risk of the primary outcome. Tubular atrophy correlated with outcome, and advanced injury was associated with worse outcomes (HR, 5.9; 95% CI, 2.25-15.47; P < 0.001). Level of kidney function at presentation strongly predicted outcome (HR per 10-mL/min/1.73 m(2) increase in estimated glomerular filtration rate, 0.63; 95% CI, 0.46-0.81; P < 0.001).Limitations: Data availability, given the retrospective nature of the study.Conclusions: Reproducibility of the classification was seen only in patients with sclerotic patterns of glomerular injury. Sclerotic pattern of glomerular injury, advanced chronic interstitial injury, and decreased kidney function all predicted poor outcomes. (C) 2014 by the National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.